Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
  • A61K31/415—1,2-Diazoles
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
  • A61K31/4164—1,3-Diazoles
  • A61K31/4184—1,3-Diazoles condensed with carbocyclic rings, e.g. benzimidazoles
• • A—HUMAN NECESSITIES
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  • A61P13/00—Drugs for disorders of the urinary system
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  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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  • A61P3/00—Drugs for disorders of the metabolism
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/04—Anorexiants; Antiobesity agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/06—Antihyperlipidemics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
  • A61P3/10—Drugs for disorders of the metabolism for glucose homeostasis for hyperglycaemia, e.g. antidiabetics
• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
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• • A—HUMAN NECESSITIES
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  • A61P9/00—Drugs for disorders of the cardiovascular system
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• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
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  • A61P9/12—Antihypertensives

Definitions

• This invention relates to the field of prevention and treatment of cardiovascular diseases and insulin resistance syndromes. Specifically, this invention relates to compounds that increase both the activity of peroxisome proliferator activated receptors (PPARs) and blocks/ antagonizes activity of the angiotensin II type 1 receptor. More specifically, this invention relates to novel clinical uses of certain angiotensin II type 1 receptor blockers (ARBs) which can increase the activity of peroxisome proliferator activated receptors (PPARs).
• PPARs peroxisome proliferator activated receptors
• PPARs Peroxisome proliferator activated receptors
• PPAR ⁇ Three subtypes of PPARs have been cloned from the mouse and human: i.e., PPAR ⁇ , PPAR ⁇ , and PPAR ⁇ .
• the PPARs are important regulators of carbohydrate and lipid metabolism, cell growth and differentiation, phenotype transition, apoptosis, neovascularization, immunoregulation and the inflammatory response.
• Compounds that activate PPARs are useful for the treatment and prevention of a variety of clinical disorders including but not limited to the metabolic syndrome, obesity, pre-diabetes, type 2 diabetes, and other insulin resistant syndromes, hypertension, atherosclerosis, dyslipidemia, inflammatory skin diseases such as psoriasis, inflammatory bowel disease, and inflammatory neurodegenerative diseases such as multiple sclerosis and Alzheimer's disease.
• the metabolic syndrome as referred to herein includes the metabolic syndrome as defined by either the World Health Organization (WHO) or the National Cholesterol Education Program (NCEP) ( Zimmet P, et al. Global and societal implications of the diabetes epidemic. Nature. (2001) 414:782-7 ; Alberti KG, Zimmet PZ.
• Examples of known compounds that can activate PPARs include thiazolidinediones (e.g. rosiglitazone, pioglitazone, MK 767 (KRP-297), MCC-555, R-483, CS-011, NC2100, DRF-2189, PAT-5A,NIP-221, netoglitazone, balaglitazone, rivoglitazone) that primarily activate PPARgamma or PPARgamma and PPARalpha, and non-thiazolidinediones that can activate any combination of PPARgamma, PPARalpha and PPARdelta (e,g, JTT-501, LSN862, DRF 4832, LM 4156, LY 510929, LY 519818, TY 51501, X 334), certain tyrosine-based derivatives (e.g.
• GW1929, GW7845 phenylacetic acid-based derivatives, phenoxazine phenyl propanoic acid derivatives (e.g. DRF 2725, DRF 2189), cinammic and dihydrocinammic acid-based derivatives (e.g. tesaglitazar (AZ 242)), and 3-Phenyl-7-propylbenzisoxazoles ( Adams AD, et al. Bioorg Med Chem Lett.
• drugs that activate PPARgamma have proven to be valuable for the prevention and treatment of type 2 diabetes and a variety of other disorders, the currently available agents cause adverse effects or aggravate certain conditions that can limit the clinical utility and safety of these ligands.
• Some of the principle limiting side effect or conditions that can be provoked or aggravated by both thiazolidinedione and non-thiazolidinedione compounds that activate PPARgamma either alone or in combination with other PPARs are fluid retention, peripheral edema, pulmonary edema, and congestive heart failure. Both rosiglitazone and pioglitazone have received regulatory approval for the treatment of type 2 diabetes in many countries including the United States and throughout the European Community.
• CHF congestive heart failure
• Fluid retention caused by PPAR activators can not only cause volume expansion and peripheral edema, but also can also induce or aggravate life-threatening conditions such as CHF and pulmonary edema. Therefore, there is considerable interest in identifying and using PPARgamma activators that do not cause substantial fluid retention and therefore do not increase the risk for edema and congestive heart failure.
• the current invention relates to the surprising discovery that certain ARBs can increase the activity of PPARgamma and can be used to treat or prevent type 2 diabetes, the metabolic syndrome, and other disorders responsive to PPAR activators or PPAR activation, without increasing the risk for fluid retention, peripheral edema, pulmonary edema, or congestive heart failure.
• ARBs can increase the activity of PPARgamma and can be used to treat or prevent type 2 diabetes, the metabolic syndrome, and other disorders responsive to PPAR activators or PPAR activation, without increasing the risk for fluid retention, peripheral edema, pulmonary edema, or congestive heart failure.
• ARBs actually decreased the risk for diabetes or whether the drugs to which they were being compared increased the risk for diabetes.
• the lower risk of diabetes reported in patients given ARBs versus beta blockers or thiazide diuretics was due to the fact that beta blockers and thiazide diuretics aggravate insulin resistance and therefore, the results of clinical studies comparing ARBs to other agents cannot be used to predict whether ,ARBs can be used to prevent or treat diabetes or other disorders responsive to PPARgamma activators.
• Epstein M and Brunner HR (eds), Hanley & Belfus, Inc., Philadelphia, (2002) pp 257-261 ).
• the ARB losartan has a neutral effect on glucose metabolism, insulin sensitivity, and serum concentrations in patients with mild hypertension ( Bernobich E, et al. Drugs (2002) 62:1295-1314 ), and in clinical studies with diabetic patients, candesartan does not appreciably alter their hemoglobin Alc, glucose concentration or lipid profile ( Easthope SE, et al. Drugs 2002;62:1253-87 ).
• angiotensin converting enzyme (ACE) inhibitors can improve insulin sensitivity and decrease the incidence of new onset type 2 diabetes in patients with hypertension
• ACE angiotensin converting enzyme
• ARBs angiotensin receptor blockers
• drugs that activate PPARgamma can cause fluid retention through a number of mechanisms.
• a surprising feature of this invention is that the fluid retention usually caused by drugs that activate PPARgamma can be prevented or attenuated by blockade of angiotensin II type 1 receptors. Because multiple mechanisms may be involved in the fluid retention caused by PPARgamma ligands, it could not have been predicted that blockade of angiotensin receptors could prevent or attenuate the fluid retention caused by PPARgamma ligands in humans. Thus, it could not have been predicted that ARBs that activate PPAR could be used to treat or prevent type 2 diabetes, the metabolic syndrome, or other insulin resistance syndromes without increasing the risk for fluid retention, edema, or congestive heart failure.
• the current discovery also provides improved methods for preventing and treating inflammatory diseases without promoting or aggravating fluid retention, peripheral edema, pulmonary edema, or congestive heart failure by administering PPAR activators that also antagonize the angiotensin II type 1 receptor.
• PPAR activators that also antagonize the angiotensin II type 1 receptor.
• compounds that activate PPAR or block angiotensin II type 1 receptors have anti-inflammatory effects, it could not have been predicted that certain compounds would have the capacity to both activate PPARs and block angiotensin receptors. Because such compounds exert anti-inflammatory effects through multiple pathways (PPAR pathway and the angiotensin receptor pathway), they provide a superior ability to treat or prevent inflammatory diseases than PPAR activators or ARBs alone.
• Such compounds that activate PPARs and block angiotensin receptors are also superior to PPAR activators because unlike currently recognized PPAR activators, the compounds of the current invention do not promote or aggravate fluid retention, peripheral edema, pulmonary edema or heart failure.
• the current invention describes the surprising finding that drugs exist and can be developed that block the angiotensin II Type 1 receptor (angiotensin receptor blockers or ARBs) and can also increase the activity of PPARgamma. That is, some drugs exist that can function as both an ARB and as a PPAR activator.
• agents include, but are not limited to, telmisartan and irbesartan and can be used to prevent or treat type 2 diabetes, the metabolic syndrome, insulin resistance, and other disorders responsive to PPARgamma activation including inflammatory disorder without causing fluid retention, edema, or congestive heart failure.
• angiotensin receptor blockers such as telmisartan and irbesartan can be surprisingly used to treat conditions that are known by those skilled in the art to be responsive to PPARgamma activators and can do so without causing fluid retention, edema, or congestive heart failure.
• ARBs that increase the activity of PPARgamma do not cause substantial fluid retention and do not increase the risk for edema and CHF, they represent a significant improvement over the currently recognized drugs that increase the activity of PPARgamma.
• Specific examples of ARBs that increase the activity of PPARgamma are provided together with a description of novel clinical uses of these agents and instructions for such use.
• This invention also describes the fact that new ARBs can be developed that also increase the activity of PPARgamma or PPARgamma and PPARalpha. Such new ARBs will also be useful for treating or preventing type 2 diabetes, the metabolic syndrome, and other disorders responsive to administration of drugs that activate PPARs without promoting fluid retention, peripheral edema, pulmonary edema, or congestive heart failure.
• the compounds of this invention also activate PPARs in addition to blocking the angiotensin II type 1 receptor, said compounds provide a more effective means of treating or preventing inflammatory and metabolic disorders including atherosclerosis than compounds that block the angiotensin II type 1 receptor but do not activate PPARs.
• an ARB or ACE inhibitor prior to or concurrently with compounds that activate PPARgamma either as separate pills or tablets or capsules, or by administering both drugs formulated in a single pill or tablet or capsule, one can also prevent or treat glucose intolerance or type 2 diabetes and other PPAR responsive disorders without causing fluid retention, edema, or congestive heart failure.
• This invention relates to methods for treating or prophylactically preventing an inflammatory or metabolic disorder in a mammal (human or non-human) without causing, promoting, or aggravating fluid retention, peripheral edema, pulmonary edema, or congestive heart failure, by administering to a mammal in need thereof, a therapeutically effective amount of a compound sufficient to partially or fully activate peroxisome proliferator activated receptors (PPARs) and partially or fully inhibit, antagonize or block the activity of angiotensin II type 1 receptors.
• PPARs peroxisome proliferator activated receptors
• the mammal is a human child, adolescent or adult and the therapeutically effective amount of the compound is used to prepare a medicament for treatment of the metabolic disorder in the human.
• said compound increases the activity of the PPAR subtype, PPARgamma or the PPARgamma-retinoid X receptor (PPARgamma-RXR) heterodimer, independently or in combination with an increase in activity of PPARalpha, PPARdelta, or both PPARalpba and PPARdelta.
• PPARgamma-RXR PPARgamma-retinoid X receptor
• said compound is administered in a pharmacologically acceptable form and in a therapeutically effective amount sufficient to prophylactically prevent, slow, delay or treat a metabolic disorder or disease selected from the group consisting of insulin resistance, glucose intolerance, impaired glucose tolerance, impaired fasting serum glucose, impaired fasting blood glucose, hyperinsulinemia, pre-diabetes, type 1 diabetes, type 2 diabetes mellitus, insulin-resistant hypertension, the metabolic syndrome, the metabolic hypertensive syndrome, (metabolic) syndrome X, the dysmetabolic syndrome, obesity, visceral obesity, hypertriglyceridemia, elevated serum concentrations of free fatty acids, elevated serum concentrations of C-reactive protein, elevated serum concentrations of lipoprotein (a), elevated serum concentrations of homocysteine, elevated serum concentrations of small, dense low-density lipoprotein (LDL)-cholesterol, elevated serum concentrations of lipoprotein-associated phospholipase (A2), reduced serum concentrations of high density lipoprotein (HDL)-cholesterol, reduced
• the compound is of the general formula: [wherein R1 is an optionally substituted hydrocarbon residue which is optionally bonded through a hetero-atom; R2 is an optionally substituted 5-7 membered heterocyclic residue having, as a group capable of constituting the ring, a carbonyl group, a thiocarbonyl group, an optionally oxidized sulfur atom or a group convertible into them; X is a direct bond or a spacer having an atomic length of two or less between the ring Y and the ring W; W and Y are independently an optionally substituted aromatic-hydrocarbon residue optionally containing a hetero-atom or an optionally substituted heterocyclic residue; n is an integer of 1 or 2; a and b forming the heterocyclic residue are independently one or two optionally substituted carbon
• the compound is formulated for oral administration. In another embodiment, the compound is formulated for topical administration.
• the compound is telmisartan, or an analog thereof. In another preferred embodiment, the compound is irbesartan, or an analog thereof, In some embodiments, the total effective daily orally administered dose is selected from the range of from about 20 mg to 1000 mg.
• the present invention further provides methods for screening compounds for treating or prophylactically preventing an inflammatory or metabolic disorder in a mammal by selecting a compound having the properties of: (a) at least partially activating peroxisome proliferator activated receptors (PPARs); and (b) at least partially inhibiting, antagonizing or blocking an activity of angiotensin II type 1 receptors.
• the method further includes selecting a compound that does not cause, promote, or aggravate fluid retention, peripheral edema, pulmonary edema, or congestive heart failure in the mammal.
• This invention relates to a method for preventing, delaying or treating insulin resistance, pre-diabetes, glucose intolerance, impaired glucose tolerance, the metabolic syndrome, type 2 diabetes, or other insulin resistance syndromes without causing systemic fluid retention, or increasing the risk for fluid retention, peripheral edema, pulmonary edema, or congestive heart failure by administering a compound that increases both the activity of peroxisome proliferator activated receptors and blocks/ antagonizes activity of the angiotensin II type 1 receptor.
• This invention further relates to novel clinical uses of certain angiotensin II type 1 receptor blockers (ARBs) based on the discovery that said compounds can increase the activity of peroxisome proliferator activated receptors (PPARs), PPAR ⁇ , PPAR ⁇ , or PPAR ⁇ , or any combination thereof, and can be used to treat and to prevent PPAR-regulated diseases and their complications including metabolic, inflammatory, proliferative, and cardiovascular diseases not previously recognized to be therapeutic targets for ARBs or more effectively than ARBs that do not activate PPARs.
• This invention further relates to methods for developing and using drugs that have the dual ability to block or inhibit activity of the renin-angiotensin-aldosterone system and to activate PPARs. Another aspect of this invention relates to methods for screening libraries of compounds to determine which are likely candidates for use in the practice of this invention.
• Body mass index (BMI) of a human patient is defined as the weight in kilograms divided by the square of the height in meters, such that BMI has units of kg/m 2 .
• Overweight is defined as the condition wherein the individual has a BMI greater than or 25 kg/m 2 and less than 30 kg/m 2 .
• Obesity is defined as the condition wherein the individual has a BMI equal to or greater than 30 kg/m 2 .
• the term obesity is used to mean visceral obesity.
• Visceral obesity is defined as a waist-to-hip ration of 1.0 in men and 0.8 in women, which, in another aspect defines the risk for insulin resistance and the development of pre-diabetes.
• Euglycemia is defined as the condition in which a subject has a fasting blood glucose concentration within the normal range, greater than 70 mg/dl (3.89 mmol/L) and less than 110 mg/dl (6.11 mmol/L).
• the word fasting has the usual meaning as a medical term.
• Impaired glucose tolerance is defined as the condition in which a subject has a fasting blood glucose concentration or lasting serum glucose concentration greater than 110 mg/dl and less than 126 mg/dl (7.00 mmol/L), or a 2 hour postprandial blood glucose or serum glucose concentration greater than 140 mg/dl (7.78 mmol/L) and less than 200 mg/dl (11.11 mmol/L).
• impaired glucose tolerance is also intended to apply to the condition of impaired fasting glucose.
• Hyperinsulinemia is defined as the condition in which a subject with insulin resistance, with or without euglycemia, in which the fasting or postprandial serum or plasma insulin concentration is elevated above that of normal, lean individuals without insulin resistance, having a waist-to-hip ration ⁇ 1.0 (for men) or ⁇ 0.8 (for women).
• insulin-sensitizing , “ insulin resistance-improving” or “ insulin resistance-lowering” are synonymous and used interchangeably.
• Patients with a predisposition for the development of IGT or type 2 diabetes are those having euglycomia with hyperinsulinemia and are by definition, insulin resistant.
• a typical patient with insulin resistance is usually overweight or obese.
• pre-diabetes is the condition wherein an individual is pre-disposed to the development of type 2 diabetes.
• Pre-diabetes extends the definition of impaired glucose tolerance to include individuals with a fasting blood glucose within the high normal range ⁇ 100 mg/dL ( J. B. Meigs, et al. Diabetes 2003; 52:1475-1484 ) and fasting hyperinsulinemia (elevated plasma insulin concentration).
• the scientific and medical basis for identifying pre-diabetes as a serious health threat is laid out in a Position Statement entitled "The Prevention or Delay of Type 2 Diabetes" issued jointly by the American Diabetes Association and the National Institute of Diabetes and Digestive and Kidney Diseases ( Diabetes Care 2002; 25:742-749 ).
• insulin resistance is defined as the clinical condition in which an individual has a HOMA-IR score > 4.0 or a HOMA-IR scope above the upper limit of normal as defined for the laboratory performing the glucose and insulin assays.
• Type 2 diabetes is defined as the condition in which a subject has a fasting blood glucose or serum glucose concentration greater than 125 mg/dl (6.94 mmol/L).
• the metabolic syndrome also called syndrome X (when used in the context of a metabolic disorder), also called the dysmetabolic syndrome is a syndrome complex with the cardinal feature being insulin resistance ( Laaksonen DE, et al. Am J Epidemiol 2002;156:1070-7 ).
• the ATP III/NCEP guidelines Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) JAMA; Journal of the American Medical Association (2001) 285:2486-2497 ), diagnosis of the metabolic syndrome is made when three or more of the following risk factors are present:
• NCEP definitions have been validated ( Laaksonen DE, et al. Am J Epidemiol. (2002) 156:1070-7 ).
• congestive heart failure includes heart failure of any etiology, including but not limited to, heart failure with diastolic dysfunction, heart failure with systolic dysfunction, heart failure associated with cardiac hypertrophy, and heart failure that develops as a result of infectious myocarditis, inflammatory myocarditis, chemical myocarditis, cardiomyopathy of any etiology, hypertrophic cardiomyopathy, congenital cardiomyopathy, and cardiomyopathy associated with ischemic heart disease or myocardial infarction,
• PPAR means one or any combination of PPARalpba, PPARgamma and PPARdelta.
• PPARgamma means one or any combination of PPARgamma1, PPARgamma2, PPARgamma3.
• PPAR activator or PPARgamma activator means any compound that, by any mechanism, increases, or causes an increase in the activity of PPARgamma or the heterodimer of PPARgamma with the retinoid X receptor (RXR), either by direct binding to either PPARgamma or RXR or indirectly through any other mechanism that affects the ability of PPARgamma or the PPARgamma-RXR heterodimer to influence gene expression.
• RXR retinoid X receptor
• Such PPAR activators may affect PPARgamma activity either alone or in combination with activation of other PPARs including either PPARalpha PPARdelta, or both PPARalpha and PPAR delta.
• a PPAR-dependent disease is a disease in which 1) administration of a PPAR ligand slows, ameliorates, stops or reverses the pathological process, and or 2) said disease is associated with impaired signal transduction upstream from PPAR and its interaction with the gene transcription machinery, and or 3) activation, partial activation or antagonism by a PPAR ligand (PPAR ⁇ , PPAR ⁇ , PPAR ⁇ ) leads to the prevention, amelioration, cure, or arrest of said disease or pathological process.
• An angiotensin II-dependent disease is a disease in which: 1) administration of a AT1 receptor antagonist slows, ameliorates, stops or reverses the pathological process, and or 2) said disease is associated with impaired signal transduction within the RAAS system, and or 3) said disease is facilitated or exacerbated by activation, of the AT1 receptor by angiotensin II, the initiating step being the by binding of angiotensin II the AT1, receptor, Because angiotensin II is a pro-inflammatory mediator, angiotensin II-dependent diseases are expected to be inflammatory in nature ( Phillips MI, Kagiyama S. Curr Opin Investig Drugs 2002;3:569-77 ).
• ARBs have the potential to ameliorate inflammatory diseases, and because PPAR ligands also function as anti-inflammatory agents with differing mechanisms of action, dual ARB/PPAR ligands would have novel, more potent, synergistic effects on inflammatory diseases ( Tham DM, et al. Physiol Genomics 2002;11:21-30 ).
• An inflammatory disease is a disease associated dysfunction of the immune system, exemplified as, but not limited to:1) increased production of inflammatory cytokines (interleukin(IL)-1beta, IL-2, IL-6, IL-8, IL-12, tumor necrosis factor- ⁇ , interferon- ⁇ , monocyte chemoattractant protein- 1), 2) increased conversion of Th2 lymphocytes to the Th1 phenotype or increased Th1/Th2 ratio, 3) inappropriate function of NK (killer) T lymphocytes resulting in auto-antibodies and lack of "self” recognition resulting in an autoimmune disease, 4) increased expression or activation of inflammatory nuclear transcription factors (NFAT, NF- ⁇ B, AP-1, JNK/STAT), 5) increased expression of iNOS.
• inflammatory cytokines interleukin(IL)-1beta, IL-2, IL-6, IL-8, IL-12, tumor necrosis factor- ⁇ , interferon- ⁇ , monocyte chemoat
• a proliferative disease is a disease associated with: 1) pathological proliferation of normally quiescent cells, 2) pathological migration of cells from their normal location (e.g. metastasis of neoplastic cells), 3) pathological expression of proteolytic enzymes such as the matrix metalloproteinases (collagenases, gelatinases, elastases), 4) pathological angiogenesis as in proliferative retinopathy and tumor metastasis.
• proteolytic enzymes such as the matrix metalloproteinases (collagenases, gelatinases, elastases)
• pathological angiogenesis as in proliferative retinopathy and tumor metastasis.
• Angiogenesis is the process by which normally quiescent endothelium responds to physiological or pathological stimuli (such as proliferating endometrium, injury, tumor growth, or diabetic retinopathy) resulting in pathological proliferation of blood vessels (neovascularization).
• Pathological angiogenesis neovascularization
• a degenerative disease is a disease associated with deterioration or destruction normal tissue, resulting from immune dysregulation resulting in the upregulation of one or more inflammatory nuclear transcription factors, inflammatory cytokines and other inflammatory molecules such as proteases (e.g, MMP-9) and iNOS, leading to pathological degeneration of the respective cell or tissue or organ which is the therapeutic target.
• heart failure includes congestive heart failure, heart failure with diastolic dysfunction, heart failure with systolic dysfunction, heart failure associated with cardiac hypertrophy, and heart failure that develops as a result of chemically induced cardiomyopathy, congenital cardiomyopathy, and cardiomyopathy associated with ischemic heart disease or myocardial infarction.
• the current invention relates to the surprising discovery that certain ARBs can also function as PPARgamma activators and can be used to prevent, delay, slow, arrest or treat insulin resistance, pre-diabetes, glucose intolerance, impaired glucose tolerance, the metabolic syndrome, type 2 diabetes, or other insulin resistance syndromes, as well as other disorders responsive to PPAR activators without increasing the risk for fluid retention, peripheral edema, pulmonary edema, or congestive heart failure.
• the current invention provides novel uses for certain ARBs for the treatment or prevention of diseases known to be responsive to drugs that increase PPARgamma activity including metabolic, endocrine, proliferative, autoimmune, immunomodulatory and inflammatory diseases and certain infective diseases.
• the present invention includes the discovery of how to make, identify, and use drugs that activate PPARgamma and that do not increase the risk of fluid retention, edema, or congestive heart failure like existing drugs that activate PPARgamma.
• This invention describes the discovery that it is possible to make and use compounds that have the dual ability to block or inhibit the renin-angiotensin-aldosterone system and the ability to activate PPARgamma.
• the invention provides specific examples of such compounds not previously recognized to have this dual ability and shows that these compounds can be used to treat conditions not previously known to be responsive to such compounds.
• this invention includes the surprising discovery that one can use certain to treat disorders responsive to treatment with PPAR activators.
• the present invention provides novel uses for ARBs that also activate PPARs for the treatment or prevention of diseases known to be responsive to PPAR ligands, in particular PPARgamma partial agonists or PPARgamma full agonists.
• Target diseases include metabolic, endocrine, proliferative, degenerative, autoimmune, atopic, and inflammatory diseases.
• the present invention also relates to the identification of novel or previously unknown ARBs that also activate PPARgamma and have a reduced propensity for causing fluid retention, edema, or congestive heart failure compared to other activators of PPARgamma.
• the present invention includes the discovery of how to identify compounds that block the rennin-angiotensin system and, at the same time, activate PPARgamma but have a significantly lower risk of causing fluid retention, edema, or congestive heart failure.
• the invention provides specific examples of ARBs not previously recognized to have this dual ability and reveals why these compounds can be used to treat conditions not previously known to be responsive to said compounds.
• this invention includes the surprising discovery that one can use certain ARBs for the purpose of treating or preventing disorders responsive to treatment with PPAR ligands, said ligands having improved safety and therapeutic efficacy.
• This invention relates to the unpredictable and surprising discovery that certain compounds can block the rennin-angiotensin system by antagonizing the AT1 receptor while activating PPARs, in particular, PPARgamma.
• this invention relates to novel clinical uses of ARBs in the prevention and treatment of PPAR-responsive conditions or diseases.
• this invention relates to novel clinical uses of ARBs in the prevention and treatment af PPAR-related conditions or diseases mediated through PPAR-dependent regulation of or interaction with related nuclear receptors, including the retinoid X receptor (RXR), retinoid orphan-related receptor (ROR), liver X receptor (LXR), farnesoid X receptor (FXR), vitamin D receptor (VDR), estrogen receptors (ER-alpha and ER-beta), glucocorticoid receptor (GR), thyroid receptor (TR) and androgen receptor (AR).
• RXR retinoid X receptor
• ROR retinoid orphan-related receptor
• LXR liver X receptor
• FXR farnesoid X receptor
• VDR vitamin D receptor
• estrogen receptors ER-alpha and ER-beta
• GR thyroid receptor
• AR androgen receptor
• this invention relates to design and identification of those ARBs that modulate the activity of PPARs, thus providing for safer and enhanced therapeutic efficacy for preventing or treating PPAR-mediated conditions or diseases, or the end-organ complications of these diseases.
• this invention relates to the identification of low toxicity PPAR ligands that are effective ARBs or ACE inhibitors by screening with AT1 receptor binding assays.
• this invention relates to methods for identifying ARBs or derivatives thereof, that can be made to further enhance their ability to activate PPAR and to more effectively treat PPAR-responsive or PPAR-mediated diseases, disorders or conditions.
• Compounds according to the present invention have renoprotective effects and are more effective for treating renal diseases or limiting the rate of progression of renal diseases (e.g. glomerular nephritis, glomerulosclerosis, nephrotic syndrome, hypertensive nephrosclerosis, polycystic kidney diseases, and diabetic nephropathy) compared to compounds that do not have this dual ability to inhibit the activity of the renin angiotensin aldosterone system and to activate PPARs.
• renal diseases e.g. glomerular nephritis, glomerulosclerosis, nephrotic syndrome, hypertensive nephrosclerosis, polycystic kidney diseases, and diabetic nephropathy
• This invention identifies ARBs that can be used as monotherapy, or in combination with one or more other pharmacological agents, or as adjunctive therapy to prevent, delay, slow, arrest or treat:
• a compound or a pharmaceutical composition according to the present invention is a PPARgamma activator which has less toxicity than other PPAR activators of the current art. Less toxicity principally refers to substantially reduced potential for fluid retention, edema or heart failure.
• Said compound or pharmaceutical composition according to the present invention may also be used prevent, delay, slow, forest or treat chronic medical pathologies and diseases, including: a) diabetic complications and diabetes-associated conditions including steatohepatitis, neuropathy, nephropathy, retinopathy, chorioretinopathy, choroidal neovascularization, retinal neovcascularization, macular degeneration, retinal detachment, glaucoma, cataract, microangiopathy, atherosclerosis, ischemic heart disease, ischemic cerebrovascular disease, stroke, peripheral arteriosclerosis, cerebral arteriosclerosis, coronary arteriosclerosis, byperinsulinemia-induced sensory disorder, obesity, heart failure, myocardial infarction, angina pectoris, cerebral infarction, chronic cardiomyopathy, cardiac fibrosis, renal disorders, glomerular nephritis, glomerulosclerosis, nephrotic syndrome, hypertensive nephrosclerosis, terminal renal disorders, microangi
• a compound or a pharmaceutical composition according to the present invention has a blood sugar reducing effect, a blood lipid reducing effect, a blood insulin reducing effect, an insulin sensitivity enhancing effect, an insulin resistance improving effect, a body weight reducing effect, a central body girth (measured as waist:hip ratio) reducing effect, a body fat mass reducing effect, through effects on PPARgamma activity, PPARgamma-RXR, or through effects on relater nuclear receptors, including FXR, LXR, ROR, cAMP-response element-binding protein (CREB), CREB-binding protein (CBP), CBP/p300, sterol regulatory binding proteins (SREBPs), steroid receptor coacovator-1 (SRC-1), PPARgamma coactivator-lalpha (PGC-lalpha), PPARgamma coactivator-1beta (PGC-1beta) and PPAR-binding protein (PBP).
• CREB
• a compound according to the present invention as an active ingredient may for example be given orally to an human at a daily dose of about 0.05 to 100 mg/kg body weight, preferably about 0.1 to 10 mg/kg body weight, preferably one to three times a day, with a single dose providing therapeutic efficacy for at least 24 hr being preferred. It is also contemplated that the therapies described in the present invention is applicable to children and adults.
• a compound according to the present invention has a blood sugar reducing effect, a blood lipid reducing effect, a blood insulin reducing effect, an insulin sensitivity enhancing effect, an insulin resistance improving effect, a body weight reducing effect, a central body girth (measured as waist:hip ratio) reducing effect, a body fat mass reducing effect, through ligand-dependent PPAR activity or PPAR-related nuclear receptor function activities.
• a PPAR is a nuclear transcription factor, and the term is used here to encompass PPAR ⁇ , PPAR ⁇ , PPAR ⁇ nuclear receptors that function as DNA-binding transcription factors having as a secondary modulating ligand for a dimeric nuclear receptor partner, such as an oil-soluble vitamin (vitamin A, vitamin D), a retinoid, or steroid hormone, and may be any of a monomer receptor, a homodimer receptor and a heterodimer receptor.
• a dimeric nuclear receptor partner such as an oil-soluble vitamin (vitamin A, vitamin D), a retinoid, or steroid hormone
• a monomer receptor is exemplified by retinoid O receptor (hereinafter abbreviated occasionally as ROR ⁇ (GenBank Accession No-L14611) ROR ⁇ (GenBank Accession No.L14160), ROR ⁇ (GenBank Accession No.U16997);Rev-erb ⁇ . (GenBank Accession No.M24898), Rev-erb ⁇ . (GenBank Accession No.L31785);ERR ⁇ . (GenBank Accession No.X51416), ERR ⁇ (GenBank Accession No.X51417);Ftz-FI ⁇ . (GenBank Accession No.S65876), Ftz-FIB.
• a homodimer receptor may for example be a homodimer formed from retinoid X receptor (hereinafter abbreviated occasionally as RXR ⁇ (GenBank Accession No.X52773), RXR ⁇ . (GenBank Accession No.M84820), RXR ⁇ .
• a heterodimer receptor may for example be a heterodimer formed from retinoid receptor X (RXR ⁇ , RXR ⁇ or RXR ⁇ ) described above together with one receptor selected from the group consisting of retinoid A receptor (hereinafter abbreviated occasionally as RAR ⁇ (GenBank Accession No.X06614), RAR ⁇ (GenBank Accession No.Y00291), RAR ⁇ (GenBank Accession No.M24857); a thyroidal hormone receptor (hereinafter abbreviated occasionally as TR ⁇ (GenBank Accession No.M24748), TR ⁇ (GenBank Accession No.M26747); a vitamin D receptor (VDR) (GenBank Accession No.J03258);a peroxisome proliferator-activated receptor (hereinafter abbreviated occasionally as PPAR ⁇ (GenBank Accession No.L02932), PPAR ⁇ (PPARdelta) (GenBank Accession No.U10375), PPAR ⁇ (GenBank Accession No.L40904)
• the current invention constitutes the surprising finding that certain ARBs can activate PPAR ⁇ , promote adipogenesis, lower (improve) insulin resistance, and can be used to treat or prevent the metabolic syndrome and components thereof (see definitions) and type 2 diabetes.
• ARBs presently approved for human use telmisartan and irbesartan are specific examples of compounds of this invention, and can surprisingly be used to treat or prevent insulin resistance, the metabolic syndrome and type 2 diabetes (i.e. lower hyperinsulinemia and/or hyperglycemia), lower triglycerides, and elevate HDL-cholesterol.
• An extension of this invention is the predictive design of derivatives of existing ARBs to improve their insulin resistance-lowering activity by increasing the EC50 for activation of PPAR ⁇ .
• ARBs do not cause substantial fluid retention and do not increase the risk for edema and heart failure, they represent a significant improvement over the currently recognized PPAR ligands.
• Specific examples of ARBs that activate PPAR ⁇ are provided together with a description of novel clinical uses of these agents and instructions for such use.
• This invention also describes the novel finding that one can derive new ARBs with greater ability to activate PPARs than existing ARBs and that such ARBs with enhanced ability to activate PPARs can be used to prevent or treat clinical disorders known to be responsive to PPAR ligands without causing the degree or extent of side effects of fluid retention, edema, or congestive heart failure caused by currently marketed PPAR ligands.
• ARBs that will significantly enhance their ability to activate PPARs and therefore enhance their ability to treat disorders known to be responsive to PPAR ligands.
• Such compounds also represent an improvement over existing ARBs as they have greater ability to activate PPARs and therefore have the added benefits of improving clinical disorders that are responsive to treatment with PPAR activators.
• PPAR ligands that have the ability to inhibit ACE activity or block angiotensin receptors.
• Such compounds represent a novel approach to treating disorders known to be responsive to PPAR ligands because they do not promote fluid retention, edema, or congestive heart failure to the extent that currently available PPAR ligands are know to do.
• ARBs that activate PPAR ⁇ are provided together with a description of novel clinical uses of these agents and instructions for such use.
• This invention also describes the novel finding that one can derive new ARBs with greater ability to activate PPARs than existing ARBs and that such ARBs, having enhanced ability to activate PPARs, can be used to prevent or treat clinical disorders known to be responsive to PPAR ligands without causing the degree or extent of side effects of fluid retention, edema, or congestive heart failure as do currently marketed PPAR ⁇ ligands.
• Such compounds also represent an improvement over existing ARBs in that they more effectively activate PPARs and therefore have the added benefits of improving clinical disorders that are responsive to treatment with PPAR activators.
• PPAR ligands that have the ability to antagonize the AT1 receptor.
• Such compounds represent a novel approach to treating disorders known to be responsive to PPAR ligands because they do not promote fluid retention, edema, or congestive heart failure to the extent that currently available PPAR ligands are know to do. While not wishing to be bound by theory, PPAR ⁇ ligands cause fluid retention through a number of mechanisms.
• a surprising feature of this invention is that the fluid retention usually caused by PPAR ⁇ ligands can be prevented or attenuated by blockade of AT1 receptors. Because blockade of the AT1 receptor does not always attenuate or prevent fluid retention in some animal models treated with PPAR ⁇ ligands, and because multiple mechanisms may be involved in the fluid retention caused by PPAR ⁇ ligands, it could not have been predicted that blockade of AT1 receptors could prevent or attenuate the fluid retention caused by PPAR ⁇ ligands in humans.
• PPAR ⁇ is not recognized to be structurally related to the AT1 receptor, ARBs would not be expected to activate PPAR ⁇ . Thus, it could not have been predicted that one could use any existing ARB to activate PPAR ⁇ . Therefore, one could not have predicted that ARBs would be useful to treat disorders responsive to PPAR ⁇ ligands or that one could design drugs that have the ability to block the AT 1 receptor while also having the ability to activate PPAR ⁇ .
• This invention describes the surprising discovery that compounds can be designed to antagonize the AT1 receptor while also possessing the ability to activate PPAR ⁇ , and that such compounds can be surprisingly useful for treating conditions known to be responsive to PPAR ⁇ ligands without promoting fluid retention, edema, or heart failure.
• telmisartan may also improve insulin instance.
• administration of telmisartan to a patient with the metabolic syndrome improved insulin resistance as determined by reduction of the HOMA-IR score (see definitions).
• telmisartan When administered to a patient with type 2 diabetes, telmisartan lowered the hyperglycemia, lowers plasma triglycerides, and elevated blood HDL-cholesterol.
• the property of reducing insulin resistance is restricted within the class of non-peptide ARBs known as "sartans", and are unpredictable surprising and non-obvious.
• This invention discloses methods of determining which "sartans” or other AT1 receptor antagonists may function as an insulin-sensitizing, insulin resistance-improving or anti-diabetic agent.
• Insulin resistant states predispose to inflammatory, proliferative and degenerative diseases such as atherosclerosis, atherogenesis, vascular stenosis or restenosis after invasive intravascular procedures, cardiomyopathy, and myocardial fibrosis.
• glucocorticoids and/or immunosuppressive agents as in the treatment of chronic inflammatory diseases and complications of immunosuppression in allograft rejection, such as osteoporosis, Cushing's disease, lipodystrophy, insulin resistance, type 2 diabetes, hyperlipidemia, transplantation-related hypertension, atherosclerosis, renal disease, arteritis and endarteritis.
• This invention predicts that administration of an ARB that also activates PPAR ⁇ would result in the clinical improvement of these conditions.
• the methods of treatment provided by this invention are practiced by administering to a human or vertebrate animal in need a dose of a compound, or a pharmaceutically acceptable salt, ester, solvate or tautomer thereof, that blocks or antagonizes the angiotensin II type 1 receptor and activates either PPARgamma alone or in combination with PPARalpha, or PPARdelta both PPARalpba and PPAR gamma.
• novel compounds used to practice this invention are set forth above. The specific diseases and associated disorders that can be treated with the compounds described in this invention are listed in Tables I through X.
• Examples of dermatological disorders and inflammatory skin disorders treatable using compounds of this invention Kertinizing skin diseases, keratitis, hidradenitis, ichthyosis, melasma Psoriasis (all forms, including p. vulgaris, p. guttata, p. discoidea, p. anthropica, p. universalis) Acne (all forms, including a. vulgaris, a. rosacea, a.
• vascular headaches common migraine
• Primary e.g. Alzheimer's disease
• secondary e.g. HIV-related dementias
• Degenerative CNS diseases e.g. Parkinson's disease, amyotropic lateral sclerosis
• Demyelinating diseases e.g. multiple sclerosis, Guillain-Barre syndrome
• Pain disorders including algesia, hyperalgesia, acute and chronic pain, allodynia
• Primary and secondary encephalitis and encephalomyelitis e.g. autoimmune encephalomyelitis, allergic encephalomyelitis
• Primary and secondary neuritis autoimmune neuritis
• Other autoimmune diseases e.g.
• Endocrine Metabolic disorders including obesity, type 1 diabetes mellitus, type 2 diabetes mellitus, gestational diabetes, impaired glucose tolerance, Cushing's syndrome (e.g. secondary to chronic glucocorticoid therapy), polycystic ovarian syndrome, osteoporosis, osteopenia, accelerated aging of tissues and organs, e.g. Werner's syndrome.
• PKD autosomal dominant PKD
• acute tubular necrosis nephrotic syndrome
• diabetic nephropathy diabetic nephropathy
• glomerulonephritis glomerulonephritis
• erectile dysfunction men and women
• Pulmonary Asthma chronic obstructive pulmonary disease (COPD)
• COPD chronic obstructive pulmonary disease
• Fibrocystic breast disease, fibroadenoma, endometriosis TABLE VIa Examples of neoplastic diseases treatable using compounds described in this invention Organ system Mulignancy / Cancer type Skin Basal cell carcinoma, melanoma, squamous cell carcinoma; cutaneous T cell lymphoma; Kaposi's sarcoma. Hematological Acute leukemia, chronic leukemia and myelodysplastic syndromes. Urogenital Prostatic, renal and bladder carcinomas, anogenital carcinomas including cervical, ovarian, uterine, vulvar, vaginal, and those associated with human papilloma virus infection.
• Neurological Gliomas including glioblastomas, astrocytoma, ependymoma, medulloblastoma, oligodendroma; meningioma, pituitary adenoma, neuroblastoma, craniopharyngioma. Gastrointestinal Colon, colorectal, gastric, esophageal, mucocutaneous carcinomas.
• Breast Breast cancer including estrogen receptor and progesterone receptor positive or negative subtypes, soft tissue tumors. Metastasis Metastases resulting from all neoplasms. Other Angiomata, angiogenesis associated with the neoplasms.
• Virus Viral infection / cancer or other virus-associated pathology HTLV T-cell leukemia/lymphoma, HTLV-associated arthritides/myelopathies.
• HPV Cervical and anogenital cancers common and anogenital (venereal) warts, including verrucae, condyloma or condyloma acuminata, related non-neoplastic (e.g ., keratitis, conjunctivitis) pre-neoplastic and neoplastic (e.g ., conjunctival epithelial neoplasms) diseases of the eye.
• HAV HBV
• HCV Hepatitis, hepatocellular carcinoma, lymphoma.
• CMV Hepatitis, retinitis, meningitis.
• HSV VSV Related mucocutaneous, oropharyngeal and genital diseases, related skin and respiratory infections, varicella-zoster, chicken pox, herpes zoster, post-herpetic neuralgia, conjunctivitis, keratoconjunctivitis, keratitis.
• HHV Exanthem subitum infectious mononucleosis.
• EBV Infectious mononucleosis, chronic fatigue syndrome, lymphoma, conjunctivitis, keratitis, and related infections of the eye.
• Adenoviruses Upper and lower respiratory tract infections, pneumonia, conjunctivitis.
• RSV Upper and lower respiratory tract infections, pneumonia.
• PMV MV RV Mumps and related manifestations, e.g., conjunctivitis.
• Measles Rubella ("German measles") and related manifestations.
• Coxsackie viruses Conjunctivitis, diabetes mellitus, respiratory infections.
• Influenza viruses Upper and lower respiratory tact infections, pneumonia.
• HIV Human Immunodeficiency Virus
• HTLV Human T-cell Lymphocyte Virus
• HPV Human Papilloma Virus
• HAV Hepatitis A Virus
• HBV Hepatitis B Virus
• HAV Hepatitis C Virus
• CMV Cytomegalovirus
• HSV Herpes Simplex Virus (Types I & II)
• HHV Human Herpes Virus
• EBV Epstein-Barr Virus
• RSV Respiratory Syncytial Virus
• VZV Varicella-Zoster Virus
• PMV Paramyxovirus
• MV Measles (Rubeola) Virus
• RV Rubella Virus Table VIII: HIV related infections and diseases treatable using compounds described in this invention
• Hematologic Non-Hodgkin's lymphoma B cell lymphoma, anemia, neutropenia, thrombocytopenia. Gastrointestinal Anorexia, gastroparesis, diarrhea, malabsorption, gastrointestinal CMV infections, esophagitis, colitis, hepatitis, lymphoma.
• Ophthalmic Conjunctivitis keratitis, keratoconjunctivitis, uveitis, retinitis, chorioretinitis, CMV retinitis, iridocyclitis, vitreitis, choroiditis, papilledema, Kaposi's sarcoma, lymphoma, ocular palsies, conjunctival warts, pre-neoplastic and neoplastic diseases of the eye.
• Oularplastic diseases Benign tumors Keratocanthoma, molluscum contagiosum, dermoid cysts, neurofibroma, neurofibromatosis, schwannoma (neurilemoma), pleiomorphic adenoma Malignant tumors Basal cell carcinoma, squamous cell carcinoma, mucoepidermoid carcinoma, melanoma, retinoblastoma, embryonal rhabdomyosarcoma, meningioma, adenoid cystic carcinoma, lymphoid tumors o fthe orbit, mesenchymal tumors (fibrous hystiocytoma) of the orbit, nasopharyngeal carcinoma.
• Conjunctivitis Acute allergic conjunctivitis (e.g. drug-related inflammation, hypersensitivity reactions), chronic (vernal) conjunctivitis, contact lens-associated conjunctivitis, e.g. giant papillary conjunctivitis, conjunctival ulceration, including ulceration associated with mucous membrane, conjunctival warts Blepharitis Inflammatory etiologies, e.g.
• Corneal injury Corneal abrasion or ulceration (e.g. contact lens-related injury), or corneal injury of any etiology*.
• Dry eye syndrome See Table below Pterygium, pinguecula Pemphigoid Includes ophthalmic pernhigori Scleritis/Episcleritis Iridocyclitis Endophthalmitis Uveal tract diseases Including glaucoma (primary and secondary etiologies) Uveitis, uveoretinitis, panuveitis, all etiologies* Vitreitis, retinitis e.g. congenital retinitis, retinitis pigmentosa. Infectious retinitis Viral (e.g. herpes, cytomegalovirus, HIV), tnberr-ulous, syphititic, fungal (e.g.
• ophthalmic diseases treatable according to the methods of this invention include diseases induced or caused by physical agents (e.g. UV radiation), chemical agents (e.g. acids, caustic solvents) immunological etiologies (e.g.
• Sjögren's Syndrome progressive systemic sclerosis, sarcoidosis, leukemia, lymphyoma, amyloidosis, hemochromatosis, 2. Infection, e.g. mumps 3.
• Injury e.g. surgical removal of lacrimal gland, irradiation, chemical burn 4.
• Medications e.g. antihistamines, antimuscarinics (atropine, scopolamine), general anesthetics (halothane, nitrous oxide), 3-adrenergic blockers (timolol, practolol), neurogenic, neuroparalytic (facial nerve palsy) II.
• retinopathy associated with glaucoma
• Cataract All etiologies and manifestations, including age-related (UV radiation) cataract, cataract associated with systemic diseases such as collagen vascular disease, diabetes mellitus, Wilson's disease Other diseases: Primary or secondary retinal detachment TABLE IXe: Ophthalmic diseases treatable using compounds described in this invention (cont'd) - Congenital degenerative retinopathie s I Primary pigmented retinopathies, all gene types - Autosomal dominant retinitis pigmentosa, e.g. rod-cone and cone-rod degenerations - Autosomal recessive retinitis pigmentosa, e.g.
• retinopathies associated with systemic diseases retinopathies associated with systemic diseases
• Secondary pigmented retinopathies retinopathies associated with systemic diseases
• Autosomal dominant pigmented retinopathies e.g. Paget's disease, Charcot-Marie-Tooth, disease, Steinert's disease, Pierre-Marie syndrome
• Autosomal recessive pigmented retinopathies e.g.
• Surgical or traumatic wounds to healthy tissues or organs Wounds caused by chemical or physical agents, e.g. ulcers caused by caustic or erosive chemicals, pressure sores, etc. Wounds associated with disease states, e.g. diabetic ulcers etc. Wounds in diseased tissues or organ
• Alzheimer's disease Parkinson's disease Amyotrophic lateral sclerosis Spinal cord ischemia, injury or transection secondary to trauma or disease III. Attenuation or arrest of the following conditions or processes: The natural aging of cells and tissues Aging induced by chemical or physical agents, e.g. sun-induced skin aging Accelerated aging associated with diseases, e.g. Werner's syndrome IV. Vitalization and revitalization of organs and tissues Promoting cell growth and preventing cell death in the aging process Promoting therapeutic or non-pathological angiogenesis as a therapeutic approach to treating diseases such as congestive heart failure and cardiomyopathy Promoting growth of organs and tissues for repair or transplantation
• the oral route of administration is the preferred mode for treatment or prevention of type 2 diabetes, the metabolic syndrome, and most other chronic disorders.
• Therapeutic agents of the invention are usually delivered or administered topically for treating disorders involving the eye or the skin except in some cases where oral administration is the preferred mode. Additionally, the agents can be delivered parenterally, especially for treatment of retinitis and degenerative retinal diseases, and for other conditions in Tables I through X, that do not respond to oral or topical therapy, or for conditions where oral or topical therapy is not feasible.
• Parenteral therapy is typically oral, intraocular, transcutaneous, intradermal, intrathecal, intramuscular, intra-articular, by inhalation, intravascular, sublingual, by suppository (e.g. per-rectum or vaginal application), by inhalation, or other parenteral route.
• a preferred way to practice the invention for dermatological or ophthalmic disorders in Tables I through X to which this method is applicable, is to apply the compound of interest, in a cream, lotion, ointment or oil based carrier, directly to the lesion.
• concentration of therapeutic compound in a cream, lotion, or oil is 0.1 to 2.5%.
• the preferred route of administration is oral, topical, intraocular or parenteral.
• Topical administration is preferred in treatment of lesions of the skin as in psoriasis, external eye as in conjunctivitis, keratitis, scleritis, squamous cell carcinoma, corneal erosion, dry eye syndrome, and anterior compartment of the eye as in glaucoma, uveitis and other diseases of the uveal tract, where such direct application is practical and clinically indicated.
• Oral administration is a preferred alternative for treatment of other lesions discussed in Tables I through X, where direct topical application is not useful as in the treatment of chronic or acute systemic diseases, and diseases of the posterior segment of the eye, as in retinitis and other retinal degenerative diseases.
• Intravascular (intravenous being the preferred route) administration may be necessary in disorders that cannot be effectively treated by topical or oral administration.
• Intraocular, transcutaneous, intradermal, intrathecal, intramuscular, intra-articular injections or other invasive technique are preferred alternative in cases where the practitioner wishes to treat one or a few specific areas or lesions depending on their location within the eye.
• the compound is delivered in an aqueous solution.
• the therapeutic compounds are injected directly into lesions (intra-lesion administration) in appropriate cases.
• Intradermal administration is an alternative for extraocular lesions.
• lntra-lesional and intradermal injections are alternative routes of application for certain lesions, e.g. extraocular neoplastic or hyperplastic lesions such as squamous cell carcinoma aud condyloma, respectively.
• Inhalation therapy is preferred for pulmonary diseases, sublingual and intra-rectal suppository is preferred for rapid delivery or in clinical situations where delivery via the oral or intravascular route is inconvenient or problematic.
• Application via vaginal topical formulation or via suppository formulation is preferred for diseases localized to the vagina or other segment of the urogenital tract.
• An effective quantity of the compound of interest is employed in treatment.
• the dosage of compounds used in accordance with the invention varies depending on the compound and the condition being treated. For example, the age, weight, and clinical condition of the recipient patient; and the experience and judgment of the clinician or practitioner administering the therapy are among the factors affecting the selected dosage. Other factors include: the route of administration, the patient, the patient's medical history, the severity of the disease process, and the potency of the particular compound.
• the dose should be sufficient to ameliorate symptoms or signs of the disease treated without producing unacceptable toxicity to the patient.
• an effective amount of the compound is that which provides either subjective relief of symptoms or an objectively identifiable improvement as noted by the clinician or other qualified observer.
• a typical oral dose is between 1 mg per day up to 1000 mg per day according to the judgment of the clinician.
• the dosage per day of the compounds of this invention will depend on the their ability to activate PPARgamma and their ability to block- the angiotensin II type 1 receptor.
• the dosages of these compounds will generally run between 0.1 mg to 1000 mg per day with a common dose being 5mg per day to 300 mg per day.
• the greater the ability to activate PPARgamma and to block the angiotensin II receptor the more effective the compound, and the lower the dosage that is an effective amount.
• An oral dosing schedule is typically, a single dose once a day. However, more than one dose can be given per day. Because of the lower incidence of undesirable side effects, the compounds of this invention can be given until improvement in the disorder of interest is observed and continued as necessary to maintain such an improved clinical state.
• the compounds may or may not be administered with food or with other agents depending on how food or other agents affects their absorption by the body and depending on the judgment of those skilled in the therapeutic art.
• the dosage can be administered once or twice a day, but the clinician can recommend more or less frequent dosing. Once a therapeutic result is achieved, the compound can be tapered or discontinued or continued according to the recommendation of the clinician. Occasionally, side effects warrant discontinuation of therapy.
• the dosage of compounds used in accordance with the invention varies depending on the compound and the condition being treated. The age, lean body weight, total weight, body surface area, and clinical condition of the recipient patient, and the experience and judgment of the clinician or practitioner administering the therapy are among the factors affecting the selected dosage. Other factors include the route of administration the patient, the patient's medical history, the severity of the disease process, and the potency of the particular compound. The dose should be sufficient to ameliorate symptoms or signs of the disease treated without producing unacceptable toxicity to the patient
• an oral dosing schedule is from about 0.1 mg to about 1000 mg once or twice a day.
• a convenient oral dose for an adult patient is approximately 80 mg to 160 mg per day but could be less or more depending on the indication.
• a dosage range for topical treatment is about 0.1 % to about 1% (weight/volume) in a gel, cream or ointment applied twice a day.
• a usual dose for intramuscular or intraocular injection is 0.25 to 2.5 mg, depending on the compartment of the eye to be treated and on the lean body mass of the patient.
• a typical dosage for intra-dermal administration is about 2.5 to 25 mg per injection per site.
• a typical dosage for intravenous or intramuscular administration in an adult patient would be between 50 and 250 mg per day given in single or divided doses depending on the judgment of the practitioner.
• Compounds useful for the application of methods described in this invention include all existing synthetic and naturally occurring agents that both increase the activity of PPARgamma and block or antagonize the activity of the angiotensin II type I receptor as well as those yet to be discovered that have such dual ability.
• Preferred compounds for the purposes of this invention include telmisartan (Micardis®), irbesartan (Avapro®) as well as any derivatives or formulations thereof and any new ARBs that may be marketed in the future that have the ability to activate PPARgamma.
• either solid or fluid unit dosage forms can be prepared.
• the compound of interest is mixed into formulations with conventional ingredients such as talc, magnesium stearate, dicalcium phosphate, magnesium aluminum silicate, calcium sulfate, starch, lactose, acacia, methylcellulose, and functionally similar materials as pharmaceutical diluents or carriers.
• Capsules are prepared by mixing the compound of interest with an inert pharmaceutical diluent and filling the mixture into a hard gelatin capsule of appropriate size.
• Soft gelatin capsules are prepared by machine encapsulation of a slurry of the compound of interest with an acceptable vegetable oil, light liquid petrolatum or other inert oil.
• Fluid unit dosage forms for oral administration such as syrups, elixirs and suspensions can be prepared.
• the water-soluble forms can be dissolved in an aqueous vehicle together with sugar, aromatic flavoring agents and preservatives to form a syrup.
• An elixir is prepared by using a hydroalcoholic (e.g., ethanol) vehicle with suitable sweeteners such as sugar and saccharin, together with an aromatic flavoring agent.
• Suspensions can be prepared with an aqueous vehicle with the aid of a suspending agent such as acacia, tragacanth, methylcellulose and the like.
• the therapeutic compound is prepared in an aqueous solution (discussed below) in a concentration, of from about 1 to about 100 mg/mL More typically, the concentration is from about 10 to 60 mg/ml or about 20 mg/ml. Concentrations below 1 mg/ml may be necessary in some cases depending on the solubility and potency of the compound selected for use.
• the formulation which is sterile, is suitable for various topical or parenteral routes including sublingual, by suppository (e.g. per-rectum or vaginal application), oral, intravascular, intradermal, by inhalation, intramuscular, intra-articular, intravenous, or other parenteral route.
• compositions may include, depending on the formulation and mode of delivery desired, pharnaaceutically-acceptable, non-toxic carriers or diluents, which include vehicles commonly used to form pharmaceutical compositions for animal or human administration.
• the diluent is selected so as not to unduly affect the biological activity of the combination.
• examples of such diluents which are especially useful for injectable formulations are water, the various saline, organic or inorganic salt solutions. Ranger's solution, dextrose solution, and Hand's solution.
• the pharmaceutical composition or formulation may include additives such as other carriers; adjuvants; or nontoxic, nontherapeutic, nonimmunogenic stabilizers and the like.
• excipients can be included in the formulation.
• examples include cosolvents, surfactants, oils, humectants, emollients, preservatives, stabilizers and antioxidants.
• Any pharmacologically acceptable buffer may be used, e.g., tris or phosphate buffers.
• Effective amounts of diluents, additives and excipients are those amounts which are effective to obtain a pharmaceutically acceptable formulation in terms of solubility, biological activity, etc.
• unit dosage form refers to physically discrete units suitable as unitary dosages for human subjects and animals, each unit containing a predetermined quantity of active material calculated to produce the desired pharmaceutical effect in association with the required pharmaceutical diluent, carrier or vehicle.
• the specifications for the unit dosage forms of this invention are dictated by and dependent on (a) the unique characteristics of the active material and the particular effect to be achieved and (b) the limitations inherent in the art of compounding such an active material for use in humans and animals.
• unit dosage form examples include tablets, capsules, pills, powder packets, wafers, suppositories, granules, cachets, teaspoonfuls, tablespoonfuls, dropperfuls, ampoules, vials, aerosols with metered discharges, segregated multiples of any of the foregoing, and other forms as herein described.
• a composition of the invention includes a therapeutic compound which may be formulated with conventional, pharmaceutically acceptable, vehicles for topical, oral or parenteral administration.
• Formulations may also include small amounts of adjuvants such as buffers and preservatives to maintain isotonicity, physiological and pH stability.
• adjuvants such as buffers and preservatives to maintain isotonicity, physiological and pH stability.
• Means of preparation, formulation and administration are known to those of skill. See generally Remington's Pharmaceutical Science 15th ed., Mack Publishing Co., Easton, Pa. (1980 ).
• a topical formulation for the treatment of ophthalmological or dermatological or other disorders listed in Tables I through X a therapeutically effective concentration of the compound is placed in a dermatological vehicle as is known in the art.
• the amount of the therapeutic compound to be administered and the compound's concentration in the topical formulations depend upon the vehicle, delivery system or device selected, the clinical condition of the patient, the side effects and the stability of the compound in the formulation.
• the physician employs the appropriate preparation containing the appropriate concentration of the therapeutic compound and selects the amount of formulation administered, depending upon clinical experience with the patient in question or with similar patients.
• the therapeutic compound is optionally administered topically by the use of a transdermal therapeutic system (see Barry, Dermatological Formulations, (1983) p. 181 and literature cited therein). While such topical delivery systems have been designed largely for transdermal administration of low molecular weight drugs, by definition they are capable of percutaneous delivery. They may be readily adapted to administration of the therapeutic compounds of the invention by appropriate selection of the rate-controlling microporous membrane.
• the therapeutic compound is formulated into solutions, suspensions, and ointments appropriate for use in the eye.
• concentrations are usually as discussed above for topico-local preparations.
• Ophthalmic formulations see Mitra (ed.), Ophthalmic Drug Delivery Systems, Marcel Dekker, Inc., New York, N.Y. (1993 ) and also Havener, W. H., Ophthalmic Pharmacology, C.V. Mosby Co., St. Louis (1983 ).
• the concentration of the therapeutic compound used depends on the mode of delivery.
• the concentration of the therapeutic compound is in the range of about 0.01% weight/weight (w/w) to about 10% w/w.
• the concentration of the therapeutic compound for this mode of delivery is in the range of about 0.025% w/w to about 2.5% w/w.
• Solid dispersions of the therapeutic compound as well as solubilized preparations can be used.
• the therapeutic compound is delivered at a concentration high enough to achieve a final concentration in the range of about 0,1 :mol/L to about 10 mol/L within the target ophthalmic compartment (e.g. the posterior chamber for the treatment of retinal diseases).
• the final concentration of the therapeutic compound is in the range of about 0.25 :mol/L to about 5 :mol/L.
• Solid dispersions of the therapeutic compound as well as solubilized preparations can be used.
• the precise concentration is subject to modest but not undue experimental manipulation well within the skill of the ordinary medical practitioner in order to optimize the therapeutic response.
• Suitable vehicles include oil-in-water or water-in-oil emulsions for preparation of ointments using mineral oils, petrolatum, lanolin, glycerin and the like as well as gels such as hydrogel.
• a preferred embodiment of the present invention involves administration of semi-solid or solid implants containing PPARgamma agonists.
• Slow or extended-release delivery systems including any of a number of biopolymers (biological-based systems), systems employing liposomes, colloids, resins, and other polymeric delivery systems or compartmentalized reservoirs, can be utilized with the compositions described herein to provide a continuous or long term source of therapeutic compound.
• Such slow release systems are applicable to formulations for delivery via topical, intraocular, oral, and parenteral routes.
• delivery intravascularly, intra-articularly, intramuscularly, intra-articularly, intradermally, or other parenteral route can be accomplished by injection, cannula or other invasive device designed to introduce precisely metered amounts of a desired formulation, to a particular compartment or tissue.
• delivery to certain areas within the eye, in situ can be accomplished by injection, cannula or other invasive device designed to introduce precisely metered amounts directly or contained in a reservoir for slow release in situ, of a desired formulation to a particular compartment or tissue within the eye (e.g. anterior or posterior chamber, uvea or retina).
• a solid or semisolid implant can be delivered subretinally using the instrumentation and methods described in U.S. Patent 5,817,075 and U.S. Patent 5,868,728 .
• a compound according to the present invention may be used in combination with a diabetes mellitus-treating agent, a diabetic complication-treating agent, an antihyperlipemic agent, a hypotensive or antihypertensive agent, an anti-obesity agent, a diuretic, a chemotherapeutic agent, an immunotherapeutic agent, and immunosuppressive agent, and the like (hereinafter referred to as a concomitant agent).
• the periods of the treatments with a compound according to the present invention and with a concomitant agent are not limited particularly, and such agents may given to a patient simultaneously or at a certain time interval.
• the dose of a concomitant drug may appropriately be determined based on the customary clinical dose.
• the ratio between a compound according to the present invention and a concomitant agent may be appropriately determined based on various factors such as the subject to be treated, the administration route, the disease or the condition to be treated and the combination of the drugs. For example, when a human is treated, 1 parts by weight of a compound according to the present invention is combined with 0.01 to 100 parts by weight of a concomitant agent.
• an agent for treating diabetes mellitus examples include an insulin formulation (e.g., animal insulin formulations extracted from, a pancreas of a cattle or a swine; a human insulin formulation synthesized by a gene engineering technology using microrganisms or methods), an insulin sensitivity enhancing agent (e.g., pioglitazone hydrochloride, troglitazone, rosiglitazone and the like), an alpha-glycosidase inhibitor (e.g., voglibose, acarbose, miglitol, emiglitate and the like), a biguanide (e.g., phenformin, metformin, buformin and the like), or a sulfonylurea (e.
• an insulin formulation e.g., animal insulin formulations extracted from, a pancreas of a cattle or a swine; a human insulin formulation synthesized by a gene engineering technology using micror
• insulin secretion-promoting agents e.g., repaglinide, senaglinide, nateglinade, mitiglinide, GLP-1 and the like
• amyrin agonist e.g. pramlintide and the like
• phosphotyrosinphosphatase inhibitor e.g. vanadic acid and the like
• an agent for treating diabetic complications examples include an aldose reductase inhibitor (e.g., tolrestat, epalrestat, zenarestat, zopolrestat, minalrestat, fidarestat, SK-860, CT-112 and the like), a neurotrophic factor (e.g., NGF, NT-3, BDNF and the like), PKC inhibitor (e.g. LY-333531 and the like), AGE inhibitor (e.g.
• aldose reductase inhibitor e.g., tolrestat, epalrestat, zenarestat, zopolrestat, minalrestat, fidarestat, SK-860, CT-112 and the like
• a neurotrophic factor e.g., NGF, NT-3, BDNF and the like
• PKC inhibitor e.g. LY-333531 and the like
• AGE inhibitor e.g.
• an active oxygen quenching agent e.g., thioctic acid or derivative thereof a bioflavonoid including flavones, isoflavones, flavonones, procyanidins, anthocyanidins, pyenogenol lutein, lycopene, vitamins E, coenzymes Q, and the like
• a cerebrovascular dilating agent e.g., tiapride, mexiletene and the like.
• An antihyperlipemic agent may for example be a statin-based compounds which is a cholesterol synthesis inhibitor (e.g., pravastatin, simvastatin, lovastatin, atorvastatin, fluvastatin, rosuvastatin and the like), a squalene synthetase inhibitor ox a fibrate compound having a triglycerade-lowering effect (e.g., gemfibrozil, bezafibrate, clofibrate, sinfibrate, clinofibrate and the like).
• a statin-based compounds which is a cholesterol synthesis inhibitor (e.g., pravastatin, simvastatin, lovastatin, atorvastatin, fluvastatin, rosuvastatin and the like), a squalene synthetase inhibitor ox a fibrate compound having a triglycerade-lowering effect (e.g., gemfibrozil,
• a hypotensive agent may for example be an angiotensin converting enzyme inhibitor (e.g., captopril, enalapril, delapril, benazepril, cilazapril, enalapril, enalaprilat, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, and the like) or an angiotensin II antagonist (e.g., losartan, candesartan cilexetil, eprosartan, valsartan, telmisartan, irbesartan, tasosartan and the like).
• angiotensin II antagonist e.g., losartan, candesartan cilexetil, eprosartan, valsartan, telmisartan, irbesartan, ta
• An antiobesity agent may for example be a central antiobesity agent (e.g., dexfenfluramine, fenfluramine, phentermine, sibutramine, amfepramone, dexamphetamine, mazindol, phenylpropanolamine, clobenzorex and the like), a pancreatic lipase inhibitor (e.g., orlistat and the like), ⁇ -3 agonist (e.g., CL-316243, SR-58611-A, UL-TG-307, SB-226552, AJ-9677, BMS-196085 and the like), apeptide-based appetite-suppressing agent (e.g., leptin, CNTF and the like), a cholecystokinin agonist (e.g., lintitript, FPL-1 5849 and the like) and the like.
• a central antiobesity agent e.g., de
• a diuretic may for example be a xanthine derivative (e.g., theobromine sodium salicylate, theobromine calcium salicylate and the like), a thiazide formulation (e.g., ethiazide, cyclopenthiazide, trichloromethiazide, hydrochlorothiazide.
• a xanthine derivative e.g., theobromine sodium salicylate, theobromine calcium salicylate and the like
• a thiazide formulation e.g., ethiazide, cyclopenthiazide, trichloromethiazide, hydrochlorothiazide.
• anti-aldosterone formulation e.g., spironolactone, triamterene and the like
• a decarboxylase inhibitor e.g., acetazolamide and the like
• a chlorbenzenesulfonamide formulation e.g.
• a chemotherapeutic agent may for example be an alkylating agent (e.g., cyclophosphamide, iphosphamide and the like), a metabolism antagonist (e.g., methotrexate, 5-fluorouracil and the like), an anticancer antibiotic (e.g., mitomycin, adriamycin and the like), a vegetable-derived anticancer agent (e.g., vincristine, vindesine, taxol and the like), cisplatin, carboplatin, etoposide and the like.
• an alkylating agent e.g., cyclophosphamide, iphosphamide and the like
• a metabolism antagonist e.g., methotrexate, 5-fluorouracil and the like
• an anticancer antibiotic e.g., mitomycin, adriamycin and the like
• a vegetable-derived anticancer agent e.g., vincristine
• An immunotherapeutic agent may for example be a microorganism or bacterial component (e.g., muramyl dipeptide derivative, picibanil and the like), a polysaccharide having immune potentiating activity (e.g., lentinan, sizofilan, krestin and the like), a cytokine obtained by a gene engineering technology (e.g., interferon, interleukin (IL) and the like), a colony stimulating factor (e.g., granulocyte colony stimulating factor, erythropoetin, and the like) and the like, among these substances, those preferred are IL-1, IL-2, IL-12 and the like.
• a microorganism or bacterial component e.g., muramyl dipeptide derivative, picibanil and the like
• a polysaccharide having immune potentiating activity e.g., lentinan, sizofilan, krestin and the like
• An immunosuppressive agent may for example be a calcineurin inhibitor/immunophilin modulator such as cyclosporine (Sandimmune, Gengraf; Neoral), tacrolimus (Prograf, FK506), ASM 981, sirolimus (RAPA, rapamycin, Rapamune), or its derivative SDZ-RAD, a glucocorticoid (prednisone, prednisolone, methylprednisolone, dexamethasone and the like), a purine synthesis inhibitor (mycophenolate mofetil, MMF, CellCept(R), azathioprine, cyclophosphamide), an interleukin antagonist (basiliximab, daclizumab, deoxyspergualin), a lymphocyte-depleting agent such as antithymocyte globulin (Thymoglobulin, Lymphoglobuline), anti-CD3 antibody (OKT3), and the like.
• an agent whose cachexia improving effect has been established in an animal model or at a clinical stage such as a cyclooxygenase inhibitor (e.g., indomethacin and the like) [ Cancer Research, Vol.49, page 5935-5939,1989 ], a progesterone derivative (e.g., megestrol acetate) [ Journal of Clinical Oncology, Vol.12, page 213-225,1994 ], a glucosteroid (e.g., dexamethasone and the like), a metoclopramide-based agent, a tetrahydrocannabinol-based agent (supra), a lipid metabolism improving agent (e.g., eicosapentanoic acid and the like) [ British Journal of Cancer, Vol.68, page 314-318,1993 ], a growth hormone, IGF-1, or an antibody against TNF-alpha, LIF, IL-6, oncostatin M which are cachexia
• the possible preferred combinations of the agents for the prevention and/or treatment of diabetes are, a PPARgamma activator with ARB activity, and:
• an amount of each other agent can be reduced in a range which is safe in light of its adverse effect.
• an insulin sensitivity enhancing agent, a biguanide and a sulfonylurea agent can be used in less dose than regular dose so that adverse effects which may be caused by these agents can be safely avoided.
• an agent for treating diabetic complications, an antihyperlipemic agent and a hypotensive agent can also be used in less dose, so that adverse effect which may be caused by them can be avoided effectively.
• a pharmaceutical composition comprising: (i) a PPAR activator in a therapeutically effective amount sufficient to prophylactically prevent, slow, delay or treat a metabolic, inflammatory, atopic, autoimmune, proliferative, or cardiovascular disorder in humans; (ii) an angiotensin II type 1 receptor antagonist in a therapeutically effective amount sufficient to prevent, slow, delay, or treat fluid retention, peripheral edema, pulmonary edema, or congestive heart failure; and (iii) a pharmaceutically acceptable carrier.
• the PPAR activator in the pharmaceutical composition can be is a thiazolidinedione selected from the group of compounds consisting of rosiglitazone, pioglitazone, KRP 297, MCC-555, R-483, CS-011, NC2100, DRF-2189, PAT-5A, NIP-221, netoglitazone, rivoglitazone and balagitazone, or an analog thereof, or a tautomeric form thereof, or a pharmaceutically acceptable salt thereof, or a pharmaceutically acceptable solvate thereof.
• the PPAR activator in the pharmaceutical composition can be a non-thiazolidmedione selected from the group of compounds consisting of tesaglitazar, farglitazar, ragaglitazar, LY818, T131, LSN862, DRF 4832, LM 4156, LY 510929, LY 519818, TY 51501, X 334, or an analog thereof, or a tautomeric form thereof, or a pharmaceutically acceptable salt thereof, or a pharmaceutically acceptable solvate thereof.
• Other thiazolidinedione or non-thiazolidinedione activators of PPARs that are familiar to those skilled in the art can also be employed.
• the angiotensin II type 1 receptor antagonist can be a compound selected from the group consisting of telmisartan, irbesartan, valsartan, losartan, candesartan, candesartan cilexetil, olmesartan, olmesartan medoximil, losartan, valsartan, eprosartan, irbesartan, tasosartan, pomisartan, ripisartan, and forasartan, or an analog thereof, or a tautomeric form thereof, or a pharmaceutically acceptable salt thereof, or a pharmaceutically acceptable solvate thereof.
• the compounds in this invention can also be given orally in combination with natural or synthetic compounds that bind to or modify the activity of the vitamin D receptor or other nuclear hormone receptor or in combination with compounds that bind to or modify the activity of the retinoid X receptor to provide for a synergistic effect in the treatment or prevention of the disorders listed in Tables I through X.
• Examples of such compounds that provide for synergistic effect when given in combination with the drugs encompassed by the current invention include vitamin D analogs, various retinoic acid derivatives, and other ligands for retinoid X receptors or retinoic acid receptors including but not limited to compounds such as LG100268, tazarotene, TTNPB, AGN 190121, adapalene or LGD1069 (Targretin).
• Synergistic therapeutic effects can be achieved by oral or topical administration of the drugs encompassed in the current invention together with orally, topically or intravenously administered drugs that bind to and modify the activity of either the vitamin D receptor, the glucocorticoid receptor, the intracellular enzyme calcineurin, the retinoid X receptors, the retinoic acid receptors, or other PPARs such as PPARalpha or PPARdelta.
• a preferred dosage range for administration of a retinoic acid derivative or retinoid would typically be from 0.1 to 100 mg per square-meter of body surface area, depending on the drug's ability to bind to or modify the activity of its cognate nuclear receptor, given in single or divided doses, orally or by continuous infusion, two or three times per day.
• the preferred dosages and routes and frequency of administration of the vitamin D analogs or retinoid compounds can be similar to the dosages and routes and frequency of administration ordinarily recommended for these agents when given without PPAR activators.
• Examples of effective retinoids are 9-cis-retinoic acid, 13-cis-retinoic acid, all-trans-retinoic acid (at-RA).
• Preferred retinoids for this purpose would include 13-cis-retinoic acid, tazarotene, or Targretin.
• a preferred dosage range for systemic administration of a vitamin D analog would typically be from 0.1 to 1.00 mg per square-meter of body surface area, depending on the drug's ability to bind to and or activate its cognate vitamin D receptor, given in single or divided doses, orally or by continuous infusion, two or three times per day.
• Examples of effective vitamin D analogs are 1,25-dihydroxy-vitamin D, calcipotriene and calcipotriol.
• the dosage range and routes and frequency of administration of PPAR activators required to achieve synergistic effects when given with vitamin D or retinoid derivatives are the same as those described elsewhere in this disclosure.
• the preferred mode of administration of these drugs for synergistic therapeutic purposes would be orally although alternatively one can use topical or parenteral routes of administration.
• the dosages and the modes and frequency of administration of the vitamin D or retinoid related compounds for synergistic topical therapy would be similar to those ordinarily recommended for these agents when given without PPAR activators.
• the dosage range and the modes and frequency required for topical administration of the flavonoid thiazolidine derivatives given in combination with vitamin D or retinoid related compounds are the same as those described elsewhere in this disclosure.
• Synergistic therapeutic effects can be achieved by oral or topical administration of the drugs encompassed in the current invention together with orally, topically or intravenously administered natural or synthetic antioxidants.
• these include ascorbic acid and its derivatives (e.g. vitamin C), the tocopherols (e.g. vitamin E, vitamin E succinate), carotenes and carotenoids (e.g. ⁇ -carotene), alpha-lipoic acid, probucols, flavones, isoflavones and flavonols (e.g. quercetin, genistein, catechin, apigenin, lutein, luteolin), lycopene, pycnogenol, glutathione and its derivatives (e.g.
• N-acetylcysteine and dithiothreitol N-acetylcysteine and dithiothreitol
• phytoestrogens and phenolic anthocyanidin and procyanidin derivatives (e.g. resveratrol, cyanidin, cinnamic acid).
• the compounds of the instant invention are further useful to suppress the mediators of neurogenic inflammation (e.g. substance P or the tachykinins), and may be used in the treatment of rheumatoid arthritis; psoriasis; topical inflammation such as is associated with sunburn, eczema, or other sources of itching; and allergies, including asthma.
• the compounds can also function as neuromodulators in the central nervous system, with useful applications in the treatment of Alzheimer's disease and other forms of dementia, pain (as a spinal analgesic), and headaches.
• the compounds of the invention can provide cytoprotection.
• ARBs, or derivatives thereof, may be tested for their ability to activate the various PPAR isoforms by utilizing standard screening methods known to those skilled in the art including but not limited to cell based transactivation assays or cell free assays that test the ability of a compound to activate a PPAR construct by measuring the output of a reporter signal that reflects the extent of the PPAR activation.
• the angiotensin receptor blocker telmisartan is added to the culture media of CV1 cells or other cells that can be transfected with a full length or partial PPAR cDNA sequence together with a reporter construct containing a PPAR response element or other appropriate response element fused to a reporter gene such as luciferase.
• telmisartan The ability of telmisartan to activate PPARgamma is tested by measuring the luciferase reporter gene activity and it is found that telmisartan causes a significant increase in reporter gene activity well above the background level present in the cells not treated with telmisartan. Similar experiments are performed with irbesartan which is also found to activate PPARgamma. Any ARBs found to activate PPARgamma according to these or other methods can be used to treat disorders known to be responsive to PPAR activators.
• chemical modifications to existing ARBs or ACE inhibitors or design derivatives thereof that can be predicted to have improved ability to activate PPARs than existing ARBs or ACE inhibitors.
• PPARgamma activators that have improved safety profile and decreased risk for causing fluid retention, edema, or congestive heart failure by testing their ability to inhibit angiotensin converting enzyme activity or their ability to block the angiotensin receptor.
• PPARgamma ligands or PPARgamma activators that also inhibit ACE activity or block angiotensin II type 1 receptors represent an improvement over existing PPAR ligands for treating PPAR responsive disorders because they have reduced likelihood of causing fluid retention, edema, or congestive heart failure.
• assays are available that can be used by those skilled in the art to determine whether a PPARgamma activator can also block the angiotensin II type I receptor or inhibit the activity of sagiotensin converting enzyme. According to the method of Groff JL, et al. (Simplified enzymatic assay of angiotensin-converting enzyme in serum. Clin Chem. 1993;39:400-4 ) or other assays that are familiar to those skilled in the art of testing compounds for their ability to inhibit angiotensin converting enzyme activity.
• the ability of a PPAR ligand to selectively block the interaction of angiotensin II (AII) with the angiotensin II type 1 receptor can be determined by the method of competitive binding of radiolabelled angiotensin II to preparations enriched in the AII type 1 receptor vs. the All type 2 receptor.
• Other methods that are familiar to those skilled in the art of identifying compounds that block the angiotensin II type 1 receptor can also be used to determine whether a PPAR activator can block the angiotensin II type 1 receptor to any degree which would be useful in identifying a PPAR. activator that is unlikely to cause fluid retention, edema, or congestive heart failure.
• Example 1 IDENTIFICATION OF ANGIOTENSIN II TYPE 1 RECEPTOR BLOCKERS THAT ACTIVATE PPARGAMMA
• PPAR ⁇ activity was determined by transactivation assays in CV-1 cells (CCL-70 line from ATCC, Bethesda, Maryland) transfected using the GenePorter transfection reagent (Gene Therapy Systems, San Diego, California) to deliver 200 ng of a PPAR ⁇ expression plasmid and 1 ⁇ g of a luciferase reporter plasmid and 400 ng pCMVSport ⁇ -gal (Gibco, Grand Island, New Jersey) as an internal control.
• test compounds telmisartan, irbesartan, valsartan, losartan, the active metabolite of losartan, the active forms of candesartan and olmesartan, rosiglitazone, or pioglitazone
• cell extracts were assayed for luciferase and ⁇ -galactosidase activity using Promega (Madison, Wisconsin) assay systems. All treatments were performed in triplicate, and normalized for ⁇ -galactosidase activity.
• Agonist concentrations yielding half maximal activation (EC 50 values) were calculated using GraphPad Prism version 3.03 (GraphPad Software, Inc., San Diego, California).
• Telmisartan significantly activated PPAR ⁇ (5-8 fold) when tested at concentrations (1- 5 ⁇ M) that can be achieved in plasma with conventional oral dosing [Stangier, 2000 #14424]. Telmisartan functioned as a moderately potent (EC 50 5.6 ⁇ M), PPAR ⁇ agonist, activating the receptor to 25% - 30% of the maximum level of activity achieved by the full agonists pioglitazone and rosiglitazone. Irbesartan activated PPAR ⁇ (2-3 fold activation) when tested at 10 ⁇ M. None of the other ARBs tested caused any significant activation of PPAR even when tested at higher concentrations (more than 10 ⁇ M).
• telmisartan and irbesartan are also activators of PPARgamma. Because PPARgamma activators can be used to treat and prevent type 2 diabetes, the metabolic syndrome, and other clinical disorders responsive to treatment with PPAR activators, these experiments demonstrate the utility of telmisartan and irbesartan for the prevention and treatment of type 2 diabetes, the metabolic syndrome, and other disorders known to be responsive to treatment with PPAR activators.
• the following examples 2 and 3 provide a generic means to measure adipocyte differentation to determine if one has an insulin-sensitizing agent.
• a mouse preadipocyte cell line (3T3-LI) obtained from the American Type Culture Collection, and the cells are grown in a Dulbecco's modified Eagle medium (DMEM) containing 4.5 g/L glucose, 50 mg/L streptomycin sulfate, 100,000 units/L penicillin-G, 0.584 g/L L-glutamine, 4 mg/L pantothenate, 8 mg/L D-biotin, and 10 mM HEPES (pH 7.2)] supplemented with 10% fetal bovine serum (FBS).
• DMEM Dulbecco's modified Eagle medium
• the cells are then plated at 1.5 ⁇ 104/cm 2 in a 96-well tissue culture plate (view plate, 96 white, Packard) coated with type 1 collagen. After the cells had reached confluence, the cells were further cultured with differentiation medium DMEM supplemented with 5% FBS, 100 ng/mL insulin, 0.1 mM isobutylmethylxanthine (IBMX), and 1 mM dexamethasone, and containing various concentrations of compounds for 4 days. The compounds added from a stock solution of dimethyl sulfoxide (DMSO). The final concentration of DMSO in the differentiation medium does not exceed 0.1% (v/v). DMSO (0.1 %) was added to the control cultures.
• DMEM dimethyl sulfoxide
• the medium was replaced with maintenance medium (DMEM supplemented with 5% ofFBS and 100 ng/mL of insulin), and the cells cultured for 2 more days.
• Activity of stimulation of adipogenesis was determined by exposure of the cells to [14-C]-acetic acid (7.4 kBq/mL), and uptake of [14-C]-acetic acid monitored after 1 h of incubation.
• the medium is discarded and the cells washed twice with phosphate-buffered saline.
• the cells are air-dried, and 200 mL of scintillation cocktail (Microscint-20, Packard) added to the wells, and counted with a Packard TopCount microplate scintillation counter.
• Stimulation of adipogenesis is expressed as concentrations equivalent to the [14-C] label uptake counts in the treatment with 10 uM telmisartan.
• test compounds insulin resistant obese fatty (fa/fa) Zucker rats (Jackson Laboratory, Bar Harbor, ME). These rats are profoundly insulin resistant with extremely high blood concentrations of insulin. Lean littermates (- /-) are used as controls. Each test compounds is administered to three Zucker rats at 10 mg/kg daily for five days after which blood samples are taken in the non-fasting state. Blood samples are collected, placed in a hematocrit centrifuge tube, and centrifuged to obtain plasma. Insulin in the collected plasma is measured by means of a radioimmunoassay kit (Linco Research, Inc, St Charles, MO).
• Insulin - sensitivity activity % ( PI in C - PI in T ) / PI in C ⁇ 100 where "PI in C” is plasma insulin in control rats and "PI in T” is plasma insulin in rats treated with test compounds.
• Example 4 A Clinical Trial Using a PPARgamma Activator to Treat Type 2 Diabetes Without Causing Fluid Retention, Edema, or Heart Failure
• telmisartan A 49 year old female with hypertension, hypertriglyceridemia, and type 2 diabetes was selected for therapy.
• the patient had a blood pressure of 160/90 mmHg, fasting serum glucose of 183 mg/dl, a fasting serum triglyceride level of 264 mg/dl, and an HDL cholesterol level of 48 mg/dl.
• the patient is taking another medication for type 2 diabetes but the dose of this medication is held constant throughout the trial.
• the patient is given telmisartan (Micardis®) at an oral dose of 80 mg/day.
• telmisartan After three weeks of telmisartan therapy, the blood pressure is reduced to 143/91 mmHg with little or no improvement in fasting glucose (188 mg/dl), triglyceride (281 mg/dl), or HDL cholesterol levels (50 mg/dl).
• the oral dose of telmisartan (Micardis® is then increased to 160 mg/day.
• the patient's blood pressure is reduced to 131/81 mmHg and there is a significant improvement in the diabetes with the glucose level reduced to 145 mg/dl, the triglyceride level reduced to 178 mg/dl, and the HDL cholesterol increased to 60 mg/dl.
• telmisartan (Micardis®) therapy is continued according to the judgment of the clinician in order to maintain the improved control of the patient's blood pressure and her type 2 diabetes.
• Example 5 A Clinical Trial Using a PPARgamma Activator to Treat the Metabolic Syndrome Without Causing Fluid Retention, Edema, or Heart Failure
• telmisartan A 59 year old female with the metabolic syndrome was selected for therapy.
• the patient had a blood pressure of 160/79 mmHg, fasting serum glucose of 118 mg/dl, fasting insulin level of 15 microunits/ml, fasting triglycerides of 129 mg/dl, and waist girth of 120 cm.
• the patient has the metabolic syndrome as defined by the National Cholesterol Education Program.
• the metabolic syndrome is associated with a 5 - 9 fold increase in the risk for developing type 2 diabetes and a 2-3 fold increase risk in cardiovascular mortality.
• the patient is given telmisartan (Micardis®) at an oral dose of 80 mg/day for treatment of the metabolic syndrome.
• telmisartan After two weeks of telmisartan therapy, the patient no longer meets the diagnostic criteria of the metabolic syndrome and her blood pressure is reduced to 130/69 mmHg, the fasting glucose is normalized to 105 mg/dl, and the fasting triglyceride level is reduced to 115 mg/dl. Clinical examination reveals no evidence of any increase in fluid retention, peripheral edema, pulmonary edema, or congestive heart failure.
• the telmisartan (Micardis®) therapy is continued according to the judgment of the clinician in order to prevent recurrence of the metabolic syndrome and prevent development of type 2 diabetes.
• Example 6 A Clinical Trial Using a PPARgamma Activator to Treat Inflammation Without Causing Fluid Retention, Edema or Heart Failure
• telmisartan A 57 year old female with osteoarthritis and inflammation as judged by elevated C-reactive protein (CRP) levels was selected for therapy.
• CRP C-reactive protein
• the patient Before administration of telmisartan, the patient had a markedly increased serum CRP level of 7.9 mg/L indicative of active inflammation.
• the patient is given telmisartan (Micardis®) at an oral dose of 80 mg/day. After 6 weeks of telmisartan therapy, the CRP level is reduced to 4.1 mg/L. After 9 weeks of therapy, the GRP level remains reduced at 3.9 mg/L and symptoms of inflammation and osteoarthritis are stabilized. Clinical examination reveals no evidence of any increase in fluid retention, peripheral edema, pulmonary edema, or congestive heart failure. The telmisartan (Micardis®) therapy is continued according to the judgment of the clinician in order to maintain the improved control of the inflammation.
• insulin-sensitizing agents with functionalities that can be used to derivitize ARBs

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  • 2003-08-08 EP EP03785060A patent/EP1536785B1/fr not_active Revoked
  • 2003-08-08 KR KR1020077030992A patent/KR100869449B1/ko active IP Right Grant
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• 2005
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• 2006
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• 2007
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• 2008
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• 2009
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• 2010
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• 2011
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